MEDICARE: CARLOS PORTER, MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	J6667	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558400168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARLOS PORTER, MD PA

Provider Business Mailing Address
First Line	:	5825 CALLAGHAN RD STE 203
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-1107
Country	:	US
Telephone Number	:	210-341-9614
Fax Number	:	210-340-5924

Provider Business Practice Location Address
First Line	:	2829 BABCOCK RD STE 117
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-6009
Country	:	US
Telephone Number	:	210-341-9614
Fax Number	:	210-340-5924

Authorized Official
Title or Position	:	PRACTICE ADMINISISTRATOR
Name	:	TAMMY RUIZ
Credential	:
Telephone Number	:	210-341-9614

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	02/18/2022

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